The postpartum period is a physiologically, emotionally and socially critical period, when most maternal deaths and health issues occur (World Health Organization (WHO), 2015). Despite postpartum care programmes, mothers can experience significant complications or death after childbirth (VanderKruik et al, 2017; Ray et al, 2018; Sighaldeh et al, 2020) and most maternal and infant deaths occur in the first month after birth (WHO, 2019). Almost half of postnatal maternal deaths occur within the first 24 hours, and 66% occur during the first week (WHO, 2019). According to the World Bank (2019), the maternal mortality ratio was 37 per 100 000 live births in Egypt in 2017. Follow up during the postpartum period can help identify concerns and improve the health of mothers and their babies postpartum.
Previous studies have shown that women's access to qualified healthcare during pregnancy, childbirth and the postpartum period can significantly reduce maternal and neonatal mortalities, as well as the number of unnecessary and costly interventions (Dalir et al, 2016; Bagheri et al, 2021). Both electronic health (eHealth) and mobile health (mHealth) are becoming prominent components of healthcare. eHealth refers to healthcare services provided with the support of information and communication technology, such as computers, mobile phones and satellite communications for health services and information (Moss et al, 2019). mHealth includes mobile-based or mobile-enhanced health solutions and describes the use of mobile telecommunication integrated with mobile and wireless healthcare delivery systems (Almotiri et al, 2016). mHealth is the practice of medicine and public health supported by mobile devices, which have been reported to potentially positively impact patient care (Ventola, 2014; Adibi, 2015). Thus, using available and widely used technology to enhance the health of women in the postpartum period could be a cost-effective health promotion alternative.
Goodman (2014) states that mobile technology is rapidly changing medicine, providing people with more power to take care of their health. With the growth of mobile technologies, there is also rapidly rising interest in using smartphones for health and wellness (Ho, 2013). The near ubiquity of mobile phones means that this technology is an emerging tool for low-cost innovation in postpartum care (Hussain-Shamsy et al, 2020; Tucker et al, 2021). The widespread use of mobile phones has led to the proliferation of mHealth promotion programmes, many specifically targeting maternal and infant health (Mildon and Sellen, 2019; Alam, 2020). These interventions have been tested in addressing perinatal depression (Hussain-Shamsy et al, 2020), breastfeeding practices (Adam et al, 2019; Ogaji et al, 2021) and perinatal mortality (Lund et al, 2014), with promising results, although widespread implementation is still in development.
However, most evidence on the impact of mHealth interventions is based on research in high-resource countries. Mobile phones' potential to significantly improve maternal and infant health in low-income countries has not been fully tested (Musiimenta et al, 2020; Biswas et al, 2021). There is little consistency in the type, frequency, timing, location and availability of health professional contact that women receive in the postpartum period, both within and between countries, as well as differences in the duration and content of contact with a health professional, as well as their qualifications (Kellie, 2017).
Mansourp (2017) explored the ownership and use of medical apps by Egyptian patients and found that 34.6% tended to use these apps, 61.8% of whom were male, older, educated and working mainly in business or as accountants. Despite widespread use of mobile phones, not all of the Egyptian population benefit from the available resources. Targeted interventions could enhance their use to improve health, especially among women.
No research has explored the effectiveness of mHealth on maternal health outcomes in Egypt. In many areas, governments and health services are investing increasing financial resources to ensure health professional contact with postpartum women. Mobile phone-based postnatal care may be an effective method to deliver follow up with the available resources and may be accessible to Egyptian mothers immediately postpartum.
Aim
The aim of this study was to evaluate the effect of mobile phone-based postnatal follow up on maternal health outcomes among low risk mothers at a hospital in Egypt.
Methods
A quasi-experimental study was conducted in 2020 at the postpartum unit of Cairo University Maternity Hospital. The phone-based postnatal care provided was based on WHO (2014) guidelines for maternal postnatal care.
Participants
A purposive sample of 70 low-risk primipara postpartum mothers was recruited from those who gave birth at the hospital. The sample size was calculated based on the proposed intervention's effect size of 0.31, a standard normal deviation for α=Zα=1.96, a standard normal deviation with power of 80%, a confidence interval of 95%, and a type I error probability of 0.05 level.
The inclusion criteria were that participants must be able to read and write, be aged 18–35 years old, with no medical disorders, having had a term or full-term normal birth of a single newborn without complications. Participants were required to provide at least two mobile phone numbers where they could be reached and a home phone number.
Mothers who did not attend antenatal care appointments or postpartum visits and those who had a stillbirth, premature newborn, newborn with severe medical problems or newborn with congenital anomalies were excluded from the study.
Participants were divided into study (those who received follow-up phone calls and SMS messages) and control (those who received standard hospital follow up) groups, with 35 mothers in each group (Figure 1). Participants were assigned to one of the two groups using a simple random sample table.
The researcher met participants at the postpartum unit immediately after birth. As follow-up data were collected by phone, each participant completed a communication plan sheet at enrollment, and provided their home phone number, their own mobile phone number, mobile phone number(s) of their partner or other members of their household, and the name and phone number of someone who would always know how to contact them. All participants provided at least two phone numbers. To minimise drop-out, participants in the study group were given reminder calls about upcoming interviews.
Data collection
Data were collected through interviews with a structured scheduled questionnaire, a postpartum assessment questionnaire and a self-rated health scale.
The structured scheduled questionnaire gathered sociodemographic data, initial and baseline assessments and obstetric history. The postpartum assessment and follow-up questionnaire was constructed by the researchers to assess the participants' physical condition. It consisted of a physical assessment after birth in hospital, an assessment of postpartum minor discomforts and an assessment of more serious postpartum signs. The instrument's content validity was assessed by three experts in maternity, and required modifications were made. The reliability coefficient was calculated with a Cronbach's alpha of 0.85, indicating high internal consistency.
Self-rated health was based on the question ‘how would you evaluate your health?’ and answers were graded on a 5-point scale: ‘very good’, ‘good’, ‘average’, ‘poor, or ‘very poor’. Subjective health is one of the most frequently used assessments of perceived health status in epidemiological research (Idler and Cartwright, 2018).
Procedure
The data collection procedure is outlined in Table 1. After collecting sociodemographic and obstetric data immediately after birth, participants in both groups were assessed by the researcher for vaginal bleeding, uterine contractions, fundal height, vital signs and voiding. Before discharge, all participants were informed about the physiological process of recovery after birth, minor discomforts and danger signs that may appear during the postpartum period. The included danger signs and symptoms were haemorrhage, infection in episiotomy sutures, abnormal vaginal discharge (colour and odour), fever, headache, blurred vision, swollen painful breasts, burning sensation during urination, swollen calf muscles with tenderness and sensation of heat. Participants were informed how, when and where they should ask for help if they experienced these issues.
Table 1. Scheme for study design
| 1 day postpartum (study and control groups) | Follow-up phone calls (study group) | 6 weeks postpartum (study and control groups) | |
|---|---|---|---|
| Phase | Pre-intervention | Intervention | Post-intervention |
| Data collected | Sociodemographic data Physical assessment Pre-discharge health education | Scheduled follow-up phone calls at 3 days, between 7 and 14 days and 6 weeks postpartum | Assessment of the postpartum period |
| Details | Participants assessed for vaginal bleeding, uterine contractions, fundal height, vital signs and voiding. Participants informed about the physiological process of recovery after birth, minor discomforts, danger signs and the importance of postpartum exercises, rest time and a healthy diet | Counselling and follow-up through 30–45 minute phone calls. Participants self-assessed physical and mental wellbeing. Participants counselled on breastfeeding, healthy meals, exercise and contraceptive methods | Assessment for minor discomforts, danger signs, breastfeeding status, contraception methods, daily exercise patterns and self-rated health |
Participants were informed of the importance of postpartum exercises, rest time and a healthy diet, as well as iron and folic acid supplementation intake for at least 3 months after birth. All information was also given in written form with details and illustrative drawings of abnormal conditions.
The follow-up plan for mothers in the study group was three phone calls on postpartum day 3, between days 7 and 14, and at the end of 6 weeks postpartum, conducted by the researcher. Each participant indicated the best days of the week and time of day to reach them and were called during their stated preferred period. The day before the call, a reminder SMS was sent. In each subsequent call, participants self-assessed their urinary and bowel functions, episiotomy healing, headache, fever, breast pain or engorgement and lochia. Additionally, participants were asked about their emotional wellbeing and their main source of social support during the first weeks of the postpartum period. Participants were counselled about breastfeeding, healthy meals, exercise and contraceptive methods.
The phone calls lasted between 30 and 45 minutes (mean=38 minutes). The control group received standard hospital follow-up care by the hospital's healthcare givers. This consisted of discharge assessment, health education and follow up at the hospital's clinic. In the case of suspected danger signs during the postpartum period, mothers call the hospital and ask for free medical advice and help. At 6 weeks postpartum, all participants in both groups were assessed for minor discomforts, danger signs, breastfeeding status, contraception methods, daily exercise patterns and self-rated health (Table 2). All health services provided to participants in both groups were free of cost.
Table 2. Outcome measures for health assessment
| Outcome measure | Components |
|---|---|
| Minor discomforts | Breast engorgement, episiotomy pain, urinary incontinence, urine retention, constipation, cracked nipple, mastitis |
| Danger signs | Vaginal bleeding, thoughts of harm, poor episiotomy healing (redness, edema, ecchymosis, discharge, separated sutures), abnormal vaginal discharge, deep venous thrombosis, fever, headache, blurred vision |
| Types of contraceptive | |
| Breastfeeding | |
| Practicing postpartum exercises | |
| Self-rated health at 6 weeks' postpartum | Very good, good, bad, very bad |
Data analysis
The statistical package for social sciences (version 21) was used for data analysis. After cleaning, descriptive analyses were conducted, followed by the t-test and Chi-square test (Mann-Whitney U-test for ordinal variables) to perform group comparisons. The level of significance was P≤0.05.
Ethical considerations
The research ethical committee of the Faculty of Nursing at Cairo University approved the research protocol (no. 2020-36). Official permission to conduct this study was obtained from the administrative authorities of the Kasr Al-Ainy Maternity Hospital of Cairo University.
Each participant was given detailed information about the study and its purpose and, if they agreed to participate, an informed consent form. The participants were informed of the voluntary nature of participation and that they could withdraw at any point without consequences for the care provided. They were guaranteed that their data would be treated confidentially and that collected personal information would be accessible only to the principal investigator.
Results
The characteristics of participants from both groups are shown in Table 3. The data revealed no differences at a statistically significant level between groups in terms of the participants' age, education, occupation status or residency. The mean age was slightly higher in the study group (26.57±4.29 standard deviation) compared to the control group (24.82±4.19 standard deviation) (P=0.09). Most participants had secondary education, were housewives and lived in rural areas. In both groups, most participants reported that their main source of social support during the 6 week postpartum period was their husband, followed by their mother and mother-in-law, with no statistically significant difference between groups.
Table 3. Characteristics of study and control groups
| Items | Study group, n=35 (%) | Control group, n=35 (%) | t | P value | |
|---|---|---|---|---|---|
| Mean age (standard deviation) | 26.57 (4.29) | 24.82 (4.19) | 1.71 | 0.09 | |
| Education | Primary school | 4 (11.4) | 2 (5.7) | 0.72 | 0.39 |
| Preparatory school | 8 (22.9) | 5 (14.3) | 0.85 | 0.35 | |
| Secondary school | 16 (45.7) | 18 (51.5) | 0.22 | 0.63 | |
| University | 7 (20.0) | 10 (28.5) | 0.69 | 0.40 | |
| Occupation | Housewife | 21 (60.0) | 17 (48.6) | 0.92 | 0.33 |
| Employee | 14 (40.0) | 18 (51.4) | 0.92 | ||
| Residence | Rural | 20 (57.1) | 24 (68.6) | 0.97 | 0.32 |
| Urban | 15 (42.9) | 11 (31.4) | 0.97 | ||
| Social support | Mother | 11 (31.5) | 9 (25.7) | 0.28 | 0.59 |
| Sister | 3 (8.5) | 3 (8.5) | 0.001 | 1.00 | |
| Husband | 12 (34.3) | 13 (37.2) | 0.06 | 0.80 | |
| Mother in law | 9 (25.7) | 10 (28.6) | 0.07 | 0.78 |
For maternal outcomes (Table 4), there were significant differences between groups related to the incidence of breast engorgement (P=0.01) and constipation (P=0.002). Although there were no statistically significant differences between groups in terms of postpartum danger signs, participants in the study group experienced a lower incidence of poor episiotomy healing and deep venous thrombosis than the control group (5.7% vs 20.0%; 2.9% vs 8.6% respectively).
Table 4. Maternal outcomes 6 weeks' postpartum
| Items | Study group, n=35 (%) | Control group, n=35 (%) | X2 | P value | |
|---|---|---|---|---|---|
| Minor postpartum discomfort | Breast engorgement | 7 (20.0) | 17 (48.6) | 6.34 | 0.01 |
| Cracked nipple | 16 (45.7) | 20 (57.1) | 0.91 | 0.33 | |
| Constipation | 18 (51.4) | 30 (85.7) | 9.54 | 0.002 | |
| Postpartum danger sign | Poor episiotomy healing | 2 (5.7) | 7 (20.0) | 3.18 | 0.07 |
| Deep venous thrombosis | 1 (2.9) | 3 (8.6) | 1.06 | 0.30 | |
| Contraceptive method/choice | Intrauterine device | 15 (42.9) | 8 (22.9) | 3.17 | 0.07 |
| Contraceptive pills | 20 (57.1) | 8 (22.9) | 8.57 | 0.003 | |
| None | 0 (0.0) | 19 (54.2) | 26.7 | <0.001 | |
| Breastfeeding | Yes | 33 (94.3) | 25 (71.4) | 6.43 | 0.01 |
| No | 2 (5.7) | 10 (28.6) | 6.43 | ||
| Practice light postpartum exercises | No | 25 (71.4) | 35 (100.0) | 11.66 | 0.001 |
| Sometimes | 10 (28.6) | 0 (0.0) | 11.66 | ||
| Self-rated health | Very good | 20 (57.2) | 11 (31.4) | 4.69 | 0.03 |
| Good | 15 (42.8) | 21 (60.0) | 2.05 | 0.15 | |
| Bad | 0 (0.0) | 3 (8.6) | 3.13 | 0.07 | |
| Very bad | 0 (0.0) | 0 (0.0) | 0.00 | 0.00 |
At 6 weeks postpartum, 40.0% of the control group did not use or choose contraceptive methods, compared to all mothers using contraceptives in the study group and significantly more participants were breastfeeding in the study group (33 vs 25, P=0.01). Furthermore, although only 28.6% of the study group practiced light exercise, this was significantly more than those in the control group (10 vs 0, P<0.001). At 6 weeks postpartum, participants in the study group reported significantly better health compared to those in the control group (very good health: 57.2% and 31.4% respectively, P=0.03).
Discussion
This study aimed to evaluate the effect of mobile phone-based postnatal follow up on maternal health outcomes among low risk mothers at a hospital in Egypt. The proposed postnatal follow up was based on WHO (2014) postpartum care guidelines and provided regular and structured follow up to reduce postpartum morbidity and improve mothers' health. The results demonstrated that mothers in the study group were less likely to develop breast engorgement and constipation and were more likely to be breastfeeding, using contraceptives, practicing light exercise and rate their health as very good at 6 weeks postpartum, compared to mothers in the control group.
The positive outcomes of the intervention carried out in the present study are in agreement with other studies on phone-based interventions for pregnant and postpartum women. Phone-based interventions and technologies have been reported to be effective in providing follow-up care to postpartum mothers (Jerin et al, 2020), counselling and information in low-resource settings (Hackett et al, 2018; McCool et al, 2020) and increasing breastfeeding duration and reducing postpartum depression (Dennis and Kingston, 2008; Niksalehi et al, 2018). Mobile tools have also been reported to improve contraceptive use, antenatal care uptake, consumption of iron-folate tablets during pregnancy, and practice of several birth preparedness methods that facilitate institutional birth (Balakrishnani et al, 2016). Shiferaw et al (2016) reported that mHealth applications during antenatal care can significantly improve birth and postnatal care service use, positively influencing the behaviour of health workers and patients. Based on the evidence of their efficacy, mHealth solutions targeting pregnant women and women in the postnatal period need to be an integral part of maternal healthcare services.
It is important to view mobile phone technology as a complementary tool to strengthen existing healthcare practices. In the present study, participants were informed about possible complications related to the postpartum period (including minor discomfort, cracked nipples, danger signs) before following up participants by phone. A combination of hospital support and phone counselling in the community has been reported to sustain higher rates of exclusive breastfeeding after hospital birth (Jerin et al, 2020). Tel et al (2018) similarly reported higher quality of life from repeated home visits combined with phone calls during the postpartum period and Miller et al (2014) concluded that phone calls may be more effective than home visits for improving women's perceived sufficiency and quality of care. However, Brodribb et al (2020) evaluated the impact of providing a universal postnatal programme and found that neither a postnatal phone call nor home visit from a public health worker was associated with continuation of breastfeeding to 4 weeks. Mobile phone technologies should be seen as complementary strategies and a natural development of existing healthcare practices.
In the present study, the majority of participants who received phone-based follow-up care rated their health as very good at 6 weeks postpartum. This may be because the follow-up phone calls gave participants the opportunity to express major or minor concerns, have their questions answered and receive any additional information. The timing may also have been an influence, as well as the type of contact provided, especially as participants who received a phone call within 48–72 hours of discharge reported significantly better health than mothers who did not. The positive effects of phone counselling or phone follow-up increase both physical and psychological quality of life in women during the postpartum period (Tel et al, 2018). Using follow-up calls provided either by a human or an interactive voice response system has a supportive approach in monitoring a patient's health problems and addressing urgent problems in a timely fashion (Houser et al, 2013). These strengths are associated with higher patient satisfaction levels. The value of mobile phone technologies is not limited to transferring information and knowledge; they also serve as a catalyst for enhancing quality of life and satisfaction with care provided (Ozdalga et al, 2012).
Despite the increased use of mHealth in healthcare interventions targeting outcomes during the postpartum period (Zhao et al 2021), using simple interventions such as text message reminders and phone-based follow up is not used in the most effective way. Most of the existing evidence, especially from the UK, is related to mHealth applications (Edwards et al, 2021; Lovell and Harris, 2021). The National Institute for Health and Care Excellence and the NHS have established clear categorisation of mHealth applications based on their functionality (Rowland et al, 2020), while less is known about the use of text messages and phone call follow up and their effectiveness in promoting health during the postpartum period. However, there is documented evidence of initiatives and the use of phone-based interventions in low- and middle-income countries (Maslowsky et al, 2016; Bangal et al, 2017; Unger et al, 2018). Simple delivery of information via text message and motivational interventions using mobile phones can promote healthy postpartum habits, risk self-assessment, and adherence to healthcare providers' recommendations.
Although the design of the present study is useful in evaluating the effectiveness and impact of programmes, the study's results may not be solely related to follow-up phone calls (Gribbons and Herman, 1996). Social support and social media may play a significant role in providing experience-based information and knowledge (Panahi et al, 2016), and these factors were not controlled for. Another unknown variable that plays a significant role in postpartum recovery is parity. Primiparous women were targeted for this study because of their lack of experience and thus their increased need for guidance and information on self care. They are also more likely to have perineal damage and less likely to resume sexual activity (Wood et al, 2022) and thus use contraception during the first few weeks after birth. Multiparous women are more likely to be confident with their own and their baby's care after birth. The generalisability of the study may therefore be limited by the small sample size and the target population. Further studies with a larger sample size, comparing multiparous and primiparous women, are recommended to confirm the present study's findings.
Conclusions
Mobile phone-based postnatal follow-up may be a useful strategy to reduce health risks and improve health of postpartum mothers, as demonstrated by the present studies findings in Egypt. Maternal healthcare services could benefit from integrating mobile phone interventions in woman- and family-centred care. Nevertheless, further studies with a larger sample size are needed to evaluate the effect of follow-up phone calls on health outcomes and lifestyle behaviour change among women in groups not included in the present study, including high-risk pregnancies, multiparous mothers and mothers who have had a caesarean section.
There is a need for evidence on the effect of the existing model of postpartum care delivery, and of different models (timing and number of postnatal phone calls) in relation to women's expectations and experiences of care during the postnatal period.
Key points
- The use of eHealth in maintaining and promoting the health and wellbeing of mothers is underused and understudied.
- The present study demonstrated that a simple intervention using mobile phone follow-up calls could promote initiation of breastfeeding and exercise, affecting self-rated health positively in the early postpartum period.
- Many postpartum-related risks such as breast engorgement, constipation, and unplanned pregnancies could be prevented by using follow-up calls during the puerperium period.
- Modern technologies could be used as a complement to existing care strategies to improve maternal health and reduce risks.
CPD reflective questions
- How can healthcare organisations integrate the use of modern technology in the provision of holistic care to mothers?
- What is the role of follow up in the prevention of suffering and reduction of risks for postpartum mothers?
- How can the health and wellbeing of mothers and newborns be promoted in a cost-effective way?